A 39-year-old, gravida 2, para 1, Japanese woman (158 cm/56.8 kg) with fetal congenital heart anomaly and polyhydramnios was scheduled for induction of delivery at 37 weeks of gestation. She requested labor analgesia.
The combined spinal-epidural block was placed at L3-L4 level, and 1.5 mg 0.5% isobaric bupivacaine with fentanyl 15 mcg was administered into the subarachnoid space. A catheter was introduced into the epidural space at cervix dilatation of 4 cm. Then, the labor analgesia was managed by programmed intermittent epidural bolus with 0.1% ropivacaine and fentanyl 2 mcg/mL was set at 8 mL with a 60-min interval. Due to polyhydramnios, pinhole amniotomy was performed at cervix dilation of 3 cm. There were no major complications until fetal bradycardia (80–90 beats per minute) occurred, which prompted the obstetric physician to go for vacuum extraction delivery. Patient delivered a female infant weighing 2468 g with an Apgar score of 7/8. Total delivery time was 2 h and 39 min (second stage of labor duration was 22 min).
After an episiotomy, a large amount of bleeding from the uterus was observed, and the obstetric physician suspected it as postpartum atony. Blood pressure was 112/89 mmHg, heart rate was 80 beats per minute, shock index was 1, and total amount of bleeding was 2800 mL at that time. We started to transfuse red blood cells and placed an intrauterine (Bakri®) balloon. At 30 min after the delivery, the total bleeding amount reached 3100 mL, and the blood pressure was decreased to 72/43 mmHg, shock index increased to 2, and SpO2 decreased to 86%. We started treatment based on a suspicious diagnosis of AFE due to sudden decrease of plasma fibrinogen level and uncontrollable bleeding from a needle hole. She was orotracheally intubated, and a central venous and a radial artery catheter was inserted. We ruled out pulmonary embolism because the central venous pressure was 5 mmHg. Besides administering low-dose noradrenaline, an occlusion balloon was inserted into the descending aorta. Uterine artery embolization was performed at radiology department. Red blood concentrates (RBCs) and fresh frozen plasma (FFP) were transfused using a rapid infusion system. In spite of those treatments, her bleeding was uncontrollable and obstetrics team decided to perform total hysterectomy, and the patient was transferred to the operating room. The time from the start of surgery to hysterectomy was 11 min. The fibrinogen level increased above 100 mg/dL after hysterectomy. However, the second interventional radiology (IVR) was required to control bleeding from the vagina. Embolization of the right internal pudendal artery and cervicovaginal branches of the right uterine artery was performed. At last, her bleeding was controlled, and the blood pressure became stable without norepinephrine administration. After hysterectomy, she was transferred to the ICU with intubation. The total bleeding amount was 12,000 mL, and the total amount of RBCs, FFP, platelet concentrate, and fibrinogen required were 38 U, 36 U, 60 U, and 8 V, respectively. The perioperative chart is shown in Fig. 1. The time series results of blood sampling are shown in Table 1.
She was extubated on the second day after surgery at ICU. On the third day, she was moved from the ICU to the general ward. On the 16th postoperative day, she was discharged from the hospital without any complications. Laboratory tests at when postpartum hemorrhage began showed that serum zinc coproporphyrin-1 and sialyl-Tn antigens were negative, but C3 (64.0 mg/dL), C4 component (10.0 mg/dL), and C1 esterase inhibitor levels (27%) were low. A month later, immunostaining examination revealed fetal components in the uterus, confirming a diagnosis of DIC type AFE.
